Job Snapshot

About Us

AF Group is committed to providing the best workers compensation product and customer service to companies and their employees across the country. Our specialized business model produces superior returns and we have a strong track record of outperforming the industry. By operating as a specialist we gain a competitive advantage and have created a lasting value for our stakeholders and customers.
Our size and specialization allow us to create significant economies of scale, and skill, for our operating units. We have the specialty expertise and financial strength and backing to make investments in technologies, processes and talent that other carriers cannot afford. This national footprint and strength is complimented by a regional market approach, with four distinct operating units that have an intimate knowledge of their customers, injured workers, and agents and brokers. Each operating unit offers superior underwriting, marketing, loss control and claims services in their niche and focused markets. The combination of a national footprint and strength with a local market expertise is what makes our organization so strong and enables our long-term outperformance of our peers.

Job Description

Medical Only Claims Specialist (R12) AF Bargaining Unit- Lansing

Primarily responsible for the investigation and management of workers' compensation claims. Conducts a 1 to 3 point contact on the managed claims, which is dependent on either the facts of the case or the claim type; determines compensability of claims, manages the medical treatment program, and assists in the return-to-work process. This includes calling and discussing potential claim activity and work-related injuries with policyholders, claimants, providers, attorneys, agents, and state agencies. Provides backup support to other MOCS and Claims Representatives; trains and mentors other team members.

Investigates workers' compensation claims with a mandatory contact to the employer within the required time frame with additional contacts to the employee or provider, as necessary.

Determines the compensability of medical only and pay and close indemnity claims by thorough investigation of the claim.

Supports the customer service work and processes for the multi-functional claims team; Communicates and collaborates with team members to ensure the appropriate and timely handling of claims in other states.

Supports the team, as required, by acting as a back up to the Service Center, MOCS, and Claims Representatives.

Mentors fellow team members and assists in the development of individual career paths.

Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure.

Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.

Documents specifics of claims with potential for subrogation recovery, including amount of potential recovery monies.

Manages medical bills for non-idemnity and indemnity claims directly associated with the claimed injury. Approves payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.

Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.

Works closely with manager on complex files or files above reserve authority.

Coordinates with outside vendors to ensure cost containment efforts.

Establishes and maintains effective working relationships with all internal and external customers.

Coordinates the Care Analytics and causation investigation initiatives as deemed appropriate by using tools such as Thru Time model, Claim Outcome model, Claim Predict Litigation models, and pharmacy program.

Determines appropriate response to regulatory inquiries.

Composes correspondence and various reports in the administration of workers compensation claims; sets appropriate diaries.

May attend agent and/or policyholder visits.

Conducts employee-employer interviews to assist in the return-to-work process.

Supports the account management process appropriately for the team's block of business.

Associate degree in insurance and/or related field with progress towards or completion of Insurance Institute of America (IIA) or other insurance related designation(s). Combinations of education and experience may be considered in lieu of a degree.

Bachelor's degree in insurance and/or related field with progress towards or completion of Insurance Institute of America (IIA) or other insurance related designation(s) and three years of insurance experience including two years experience as a claims representative with experience in reviewing, investigating, and managing claims.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

General knowledge of claims operations specifically claims processes.

Ability to work effectively in a multifunctional business unit.

Excellent verbal and written communication skills.

Ability to use diplomacy, discretion, and appropriate judgment when responding to inquiries from staff and external customers as well as anticipating needs of the department.

Ability to effectively exchange information clearly and concisely, and present ideas, report facts and other information and respond to questions as appropriate.

Knowledge of Workers Compensation in one or more states including jurisdictional laws.

For this posting, due to staffing and workload needs, an additional requirement has been added.

Candidates must have a current Claims Adjuster License or must obtain a Claims Adjuster License within 90 calendar days after placement in this position.

Failure to obtain a Claims Adjuster License within 90 calendar days after placement will result in a failure of Trial period, (Section 9.6.1 of CBA) which states that "the employee will be disqualified from the position. In these instances, initially, the employee will be placed on the recall list in accordance with Article 8.8 of the Collective Bargaining Agremeent and will be provided recall rights at the pay range of the job held before the trial period."

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards. Travel may be required.